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Explore Referent• Principal: [Full Name], residing at [Address], hereinafter referred to as the “Principal.”
• Healthcare Agent: [Full Name], residing at [Address], hereinafter referred to as the “Agent.”
The principal hereby designates the Agent to make healthcare decisions for the principal if the principal is unable to make or communicate such decisions. This includes the authority to:
Consent to, refuse, or withdraw consent for medical treatment, surgery, or diagnostic procedures.
Employ or discharge healthcare personnel.
Access and disclose medical records, subject to HIPAA and relevant privacy laws.
Make end-of-life decisions, including the use or withdrawal of life-sustaining measures, consistent with the principal’s known wishes or best interests.
Consent to, refuse, or withdraw consent for medical treatment, surgery, or diagnostic procedures.
Employ or discharge healthcare personnel.
Access and disclose medical records, subject to HIPAA and relevant privacy laws.
Make end-of-life decisions, including the use or withdrawal of life-sustaining measures, consistent with the principal’s known wishes or best interests.
This Medical Power of Attorney becomes effective only when the principal’s primary physician or another qualified medical professional determines that the principal is unable to make or communicate informed medical decisions.
This Medical Power of Attorney is durable and shall not be affected by the Principal’s incapacity, except as stated herein or by operation of law.
• The Agent must make decisions in line with the Principal’s known wishes, religious beliefs, or moral values.
• If the Principal’s preferences are unknown, the Agent must act in the Principal’s best interests.
• The Agent must keep records of the medical decisions made on behalf of the Principal.
The Principal may revoke this Medical Power of Attorney at any time, orally or in writing, as permitted by law.
“I intend for my Agent to be treated as my personal representative for HIPAA and other applicable medical privacy regulations. My Agent may access any and all of my medical information necessary to make informed healthcare decisions.”
This Medical Power of Attorney is governed by the laws of the State of [State].
Signatures and Acknowledgment
Principal’s Signature: _________________________ Date: ______________
Printed Name: ________________________________
Agent’s Signature (if required by state law): ______________________ Date: __________
(Notarization or Witness Requirements Here)
Each template already follows legal structure and best practices.
The agreement is automatically filled and adapted to your inputs.
Check the generated document, make edits if needed, and download a ready-to-use agreement.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Frequently asked
A medical power of attorney, also called a healthcare proxy, is a legal document that appoints someone you trust to make medical decisions on your behalf if you become unable to do so. It can also outline your treatment preferences to guide your chosen decision-maker.
It ensures that medical choices reflect your personal values and wishes when you cannot communicate them yourself — providing peace of mind for you and clarity for healthcare providers and loved ones.
Prepare one in advance of any potential incapacity, serious illness, major surgery, or life-changing medical event to ensure your healthcare decisions are honored.
Name a trusted healthcare agent, clearly define the scope of their authority, include any treatment limitations or preferences, and complete the legal formalities such as signing, dating, and having the document properly witnessed or notarized.
Create a customized, state-compliant healthcare proxy in minutes with our AI-powered document builder — ready to protect your wishes.
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